ID
10639
Description
CALGB: 49903 ADVERSE EVENT FORM NCT00053339 Trastuzumab With or Without Tamoxifen in Treating Women With Progressive Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A73D2363-5625-477E-E034-0003BA0B1A09
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Versions (2)
- 12/18/14 12/18/14 - Martin Dugas
- 6/3/15 6/3/15 -
Uploaded on
June 3, 2015
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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CALGB: 49903 ADVERSE EVENT FORM NCT00053339
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
Description
Patient demographics
Description
Patient'sName
Data type
text
Description
ParticipatingGroup
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PatientHospitalNumber
Data type
text
Description
ParticipatingGroupProtocolNo.
Data type
text
Description
AffiliateName
Data type
text
Description
ParticipatingGroupPatientID
Data type
text
Description
ADR Report
Description
Expected Adverse Events
Description
IMTCodeduplicate
Data type
text
Description
CTCAdverseEventTerm
Data type
text
Description
CTCAdverseEventGrade
Data type
text
Description
CTCAdverseEventAttributionCode
Data type
text
Description
Person Completing Form
Description
Ccrr Module For Calgb: 49903 Adverse Event Form
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INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1521800 (UMLS 2011AA ObjectClass)
C25175 (NCI Thesaurus Property)
C1522646 (UMLS 2011AA Property)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0445356 (UMLS 2011AA)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)